EP4101931A1 - Verabreichungsplan - Google Patents

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Publication number
EP4101931A1
EP4101931A1 EP22173856.0A EP22173856A EP4101931A1 EP 4101931 A1 EP4101931 A1 EP 4101931A1 EP 22173856 A EP22173856 A EP 22173856A EP 4101931 A1 EP4101931 A1 EP 4101931A1
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Prior art keywords
cancer
genes
expression level
methylenetetrahydrofolate
folate
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French (fr)
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Yvonne WETTERGREN
Elisabeth ODIN
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Isofol Medical AB
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Isofol Medical AB
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    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q1/00—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions
    • C12Q1/68—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions involving nucleic acids
    • C12Q1/6876—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes
    • C12Q1/6883—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes for diseases caused by alterations of genetic material
    • C12Q1/6886—Nucleic acid products used in the analysis of nucleic acids, e.g. primers or probes for diseases caused by alterations of genetic material for cancer
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/495—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having six-membered rings with two or more nitrogen atoms as the only ring heteroatoms, e.g. piperazine or tetrazines
    • A61K31/505—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim
    • A61K31/519—Pyrimidines; Hydrogenated pyrimidines, e.g. trimethoprim ortho- or peri-condensed with heterocyclic rings
    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q2600/00—Oligonucleotides characterized by their use
    • C12Q2600/106—Pharmacogenomics, i.e. genetic variability in individual responses to drugs and drug metabolism
    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q2600/00—Oligonucleotides characterized by their use
    • C12Q2600/158—Expression markers

Definitions

  • the present invention relates to a method for determining a folate substance administration regime, especially as part of a cancer treatment.
  • Folic acid and various kinds of folic acid derivatives are commonly used as parts of different cancer treatments.
  • leucovorin folinic acid, LV
  • levo-isomer levoleucovorin
  • levoleucovorin and also other reduced folates
  • 5-FU + LV (FLV) treatment may be used alone or in combination with oxaliplatin or irinotecan as adjuvant as well as palliative treatment of colorectal cancer.
  • Leucovorin or levoleucovorin is also used in combination with methotrexate as a "rescue agent" in order to reduce side effects of the methotrexate.
  • [6R]-5,10-methylenetetrahydrofolate (6R-methylenetetrahydrofolate, [6R]-MTHF, Modufolin ® ) is an endogenous folate metabolite now being developed for direct administration to patients with the aim to increase the efficacy and decrease the side effects of chemotherapeutic agents used in the treatment of solid tumors. It has been suggested that the use of the endogenous folate [6R]-MTHF in cancer treatment is more favourable than the use of other folic acid derivatives, e.g. leucovorin, since [6R]-MTHF is the active agent resulting from folate metabolism. In particular, it has been suggested that the administration of e.g.
  • leucovorin is less efficient than the administration of [6R]-MTHF, since many metabolic steps are required in order to achieve the active species, i.e. [6R]-MTHF, from leucovorin.
  • [6R]-MTHF active species
  • Fig. 1 shows estimated survival functions by level of SLC46A1 gene expression in colorectal cancer tumor.
  • the present invention relates to a method for determining a folate substance administration regime, said method comprising:
  • the step of quantifying the expression level of at least one of said genes is performed by real-time quantitative PCR, and the quantified expression level for each of said genes is preferably expressed as the Ct value normalized to the mean of the Ct values for the endogenous house-keeping genes ⁇ -actin and GAPDH. This normalized Ct value is also referred to as the ⁇ Ct value.
  • the step of establishing whether said expression level is high or low comprises comparing the expression level of at least one of said genes with a predetermined cutoff value. Suitable cutoff values have been experimentally established, and the optimal cutoff values for available data are as follows:
  • Each predetermined cutoff value is expressed as the Ct value normalized to the mean of the Ct values for the endogenous house-keeping genes ⁇ -actin and GAPDH.
  • the folate substance upstreams of [6R]-methylenetetrahydrofolate in the metabolic pathway is suitably selected from the group consisting of folic acid (pteroyl-L-glutamic acid), mefolinate ([6R,S]-5-CH 3 -tetrahydrofolate), Metafolin ® ([6S]-5-CH 3 -tetrahydrofolate), CoFactor ® ([6R,S]-5-CH 2 -tetrahydrofolate), leucovorin ([6R,S]-5-CHO-tetrahydrofolate), and/or levoleucovorin ([6S]-5-CHO-tetrahydrofolate).
  • folic acid pteroyl-L-glutamic acid
  • mefolinate [6R,S]-5-CH 3 -tetrahydrofolate
  • Metafolin ® [6S]-5-CH 3 -tetrahydrofolate
  • the folate substance upstreams of [6R]-methylenetetrahydrofolate is levoleucovorin or leucovorin.
  • the folate substance administration regime is suitably part of a cancer treatment.
  • the present invention for the first time presents a way to provide a customized folate treatment, especially as part of cancer treatment.
  • the present invention has solved the problem of how to predict which patients who will benefit from a folate treatment involving folic acid or folic acid derivatives, like leucovorin, and also which patients who are more suited to be administered [6R]-methylenetetrahydrofolate directly.
  • the invention is based on the surprising insight that the expression level of certain genes has a direct effect on a patient's capability to metabolize folic acid and its derivatives into [6R]-methylenetetrahydrofolate.
  • the identified genes belong to three different categories:
  • the method according to the invention involves quantifying the expression of at least one of the genes belonging to the folate transport group, i.e. SLC46A1, SLC19A1, and ABCC3.
  • the method according to the invention involves quantifying the expression of at least one of the genes belonging to the folate glutamation group, i.e. FPGS, and GGH.
  • the method according to the invention involves quantifying the expression of at least one of the genes belonging to the folate metabolism group, i.e. MTHFD1L, MTHFD1, MTFMT, and ATIC.
  • the method according to the invention involves quantifying the expression of at least one gene from each group, i.e. at least one of the genes SLC46A1, SLC19A1, and ABCC3; at least one of the genes FPGS, and GGH; and at least one of the genes MTHFD1L, MTHFD1, MTFMT, and ATIC.
  • the cancer may be selected from the group consisting of breast cancer, gastric cancer, gall bladder cancer, bile duct cancer, colon cancer, rectal cancer, liver cancer, pancreatic cancer, head and neck cancer, and mesotheolioma cancer.
  • the cancer treatment may involve the administration of an anti-cancer agent selected from the group consisting of antifolates, anthracyclines, platinum derivatives, topoisomerase inhibitors, and antimetabolites, such as fluorouracil.
  • the sample to be analyzed according to the inventive method is suitably drawn from a tumor of said patient, preferably a solid tumor.
  • the present invention also relates to a kit for determining a folate substance administration regime, said kit comprising:
  • the inventive concept of identifying specific patient groups being susceptible for specific folate substance treatments also provides for establishing new further medical uses of folate substances upstreams of [6R]-MTHF in the metabolic pathway, [6R]-MTHF, and anti-cancer agents.
  • the present invention provides for
  • the present invention provides for:
  • the present invention for the first time provides for the possibility to establish which patients that would benefit from the treatment of e.g. folic acid or leucovorin, and also which patient that would not benefit from such a treatment.
  • patients that do not have the capability to metabolize leucovorin are suitably administered the active folate metabolite, [6R]-MTHF, directly.
  • genes identified are SLC46A1; SLC19A1; FPGS; ABCC3; MTHFD1L; GGH; MTHFD1; MTFMT; and ATIC. All these genes belong to the state of the art, and their sequences are well-characterized. In accordance with the present invention, each of these genes are described by reference to their respective reference human mRNA sequence(s) as provided by NCBI (National Center for Biotechnology Information).
  • NM_X n .Y indicates an mRNA sequence
  • X n indicates the accession number
  • Y indicates the version number.
  • the version numbers are continually updated, and in Table 1, the most recent version by the indicated date is provided.
  • genes SLC46A1; SLC19A1; FPGS; ABCC3; MTHFD1L; GGH; MTHFD1; MTFMT; and ATIC to be quantified in accordance with the present invention are completely and unambiguously identified by the accession numbers and version numbers indicated in Table 1 below.
  • similar reference sequences may also have the ability to provide an accurate identification.
  • other versions of the reference sequences as provided by NCBI also have the ability to provide an accurate identification.
  • mRNA splice variants are described by reference to more than one mRNA reference sequence. "Splicing" is a process occurring during gene expression, which results in a single gene coding for multiple proteins. In this process, particular exons of a gene may be included within, or excluded from, the mRNA produced from that gene, i.e. the gene may give rise to several different mRNA splice variants.
  • the gene SLC46A1 may alternatively be referred to as G21, HCP1, or PCFT.
  • the gene SLC19A1 may alternatively be referred to as CHMD, FOLT, IFC1, REFC, or RFC1.
  • the gene FPGS may alternatively be referred to as RP11-228B15.1.
  • the gene ABCC3 may alternatively be referred to as ABC31, EST90757, MLP2, MOAT-D, MRP3, or cMOAT2.
  • the gene MTHFD1L may alternatively be referred to as FTHFSDC1, MTC1THFS, RP1-292B18.2, or dJ292B18.2.
  • the gene GGH may alternatively be referred to as GH.
  • the gene MTHFD1 may alternatively be referred to as MTHFC, or MTHFD.
  • the gene MTFMT may alternatively be referred to as COXPD15, or FMT1.
  • the gene ATIC may alternatively be referred to as AICAR, AICARFT, IMPCHASE, OK/SW-cl.86, or PURH.
  • the present invention relates to a method for determining a folate substance administration regime, where the administration regime is determined depending on the expression level of one or more of the genes SLC46A1, SLC19A1, FPGS, ABCC3, MTHFD1L, GGH, MTHFD1, MTFMT, and ATIC.
  • the administration regime may involve the administration of e.g. leucovorin.
  • this patient category also benefits from the administration of [6R]-MTHF.
  • high expression level an expression level of one of said genes, which involves a statistically significant decreased risk of recurrent disease (colorectal cancer), measured as disease-free survival, in patients treated with 5-FU in combination with leucovorin.
  • low expression level an expression level of one of said genes, which involves a statistically significant increased risk of recurrent disease (colorectal cancer), measured as disease-free survival, in patients treated with 5-FU in combination with leucovorin.
  • the expression of one or more genes of interest is suitably examined by quantification by real-time quantitative PCR, which is a well-established technique used in the field for analysing gene expression levels.
  • the quantified expression level for each of said genes is preferably expressed as the Ct value normalized to the mean of the Ct values for the endogenous house-keeping genes ACTB ( ⁇ -actin) and GAPDH.
  • each of these housekeeping genes are described by reference to their respective reference human mRNA sequence(s) as provided by NCBI (National Center for Biotechnology Information).
  • NM_X n .Y indicates an mRNA sequence
  • X n indicates the accession number
  • Y indicates the version number.
  • the version numbers are continually updated, and in Table 2, the most recent version by the indicated date is provided.
  • the house-keeping genes ACTB ( ⁇ -actin) and GAPDH to be quantified in accordance with the present invention are completely and unambiguously identified by the accession numbers and version numbers indicated in Table 2 below. However, it is to be understood that similar reference sequences may also have the ability to provide an accurate identification. In particular, other versions (i.e. reference sequences having the same accession numbers, but different version numbers) of the reference sequences as provided by NCBI also have the ability to provide an accurate identification.
  • Table 2 Housekeeping gene Transcript variant Reference human mRNA sequence(s) (NCBI Reference Sequence(s))-Accession number Base pairs Version number as of 28 Jan 2014 ACTB NM 001101 1852 3 GAPDH 1 NM_002046 1421 5 2 NM 001256799 1455 2
  • the gene ACTB may alternatively be referred to as BRWS1, or PS1TP5BP1.
  • the gene GAPDH may alternatively be referred to as CDABP0047, G3PD, or GAPD.
  • Ct is defined as the number of cycles required for the fluorescent signal to cross the threshold (i.e. exceeds background level).
  • Ct levels are inversely proportional to the amount of target nucleic acid in the sample (i.e. the lower the Ct level the greater the amount of target nucleic acid in the sample).
  • Normalization to an endogenous control allows correction of results that can otherwise be skewed by differing amounts of input nucleic acid template. Any gene shown to be expressed at the same level in all study samples can potentially be used as an endogenous control.
  • the step of establishing whether an expression level is high or low suitably comprises comparing the expression level of a gene of interest with a predetermined cutoff value. Suitable cutoff values have been experimentally established, and are listed in Table 6 below.
  • assays that may be used for the analyzing the expression of the genes according to the invention are exemplified in Tables 3 and 4 (see also Example 1 and Table 5 below ("Assay ID”)).
  • the assays are provided by "Life Technologies", and detailed information on each assay can be found on their website: http://www.lifetechnologies.com/.
  • the gene expression is preferably analyzed in a tissue sample drawn from a tumor of a patient, typically by a biopsy.
  • the sample is analyzed for the expression of one or more genes from one of the gene groups mentioned above (i.e. genes involved in folate transport, folate polyglutamation, and folate metabolism, respectively).
  • the sample is analyzed for the expression of one or more genes from two of the groups.
  • the sample is analyzed for the expression of one or more genes from all of the three respective groups.
  • the sample is analyzed for the expression of all nine genes.
  • the sample is analyzed for the expression of SLC46A1 and/or SLC19A1.
  • [6R]-methylenetetrahydrofolate Some alternative denotations of [6R]-methylenetetrahydrofolate are: Modufolin ® , [6R]-5,10- methylenetetrahydrofolate, [6R]-methylene-THF, [6R]-5,10-methylene-THF, [6R]-MTHF, [6R]-5,10-MTHF, [6R]-5,10-CH 2 -THF, [6R]-5,10-CH 2 -tetrahydrofolate, [6R]-5,10-CH 2 -H 4 PteGlu n ,
  • the IUPAC name of methylenetetrahydrofolate is: N-[4-(3-amino-1-oxo-1,4,5,6,6a,7-hexahydroimidazo[1,5-f]pteridin-8(9H)-yl)benzoyl]-L-glutamic acid.
  • a folate substance upstreams of [6R]-MTHF in the metabolic pathway is meant any folate substance that upon administration to a patent is metabolized in the body to [6R]-MTHF.
  • examples of such substances are folic acid (pteroyl-L-glutamic acid), mefolinate ([6R,S]-5-CH 3 -tetrahydrofolate), Metafolin ® ([6S]-5-CH 3 -tetrahydrofolate), CoFactor ® ([6R,S]-5-CH 2 -tetrahydrofolate), leucovorin ([6R,S]-5-CHO-tetrahydrofolate), and levoleucovorin ([6S]-5-CHO-tetrahydrofolate).
  • the expression "metabolic pathway” is a recognized expression within biochemistry and relates to a series of chemical reactions in a cell, catalyzed by enzymes and connected by their intermediates, i.e. the reactants of one reaction are the products of the previous one.
  • the expression "upstreams of” defines that the folate substance in question is involved in a chemical reaction which occurs at an earlier stage in the series of chemical reactions than the chemical reaction leading to [6R]-MTHF.
  • the invention refers to a general method for determining a folate substance administration regime, it is particularly suitable for determining a folate administration regime which is part of a cancer treatment.
  • the present invention may be used in connection to the treatment of several cancer forms, e.g. breast cancer, gastric cancer, gall bladder cancer, bile duct cancer, colon cancer, rectal cancer, liver cancer, pancreatic cancer, head and neck cancer, and mesotheolioma cancer.
  • cancer forms e.g. breast cancer, gastric cancer, gall bladder cancer, bile duct cancer, colon cancer, rectal cancer, liver cancer, pancreatic cancer, head and neck cancer, and mesotheolioma cancer.
  • the cancer treatment may involve the administration of various anti-cancer agents, like antifolates, anthracyclines, platinum derivatives, topoisomerase inhibitors, and antimetabolites.
  • the anti-cancer agents may be used alone or in combination. Suitable administration regimes of anti-cancer agents are known to a person skilled in the art.
  • antifolates to be used in accordance with the present invention are pemetrexed (Alimta ® ), raltitrexed (Tomudex ® ), methotrexate, and pralatrexate, all of which are transported by RFC (Reduced Folate Carrier).
  • Other antifolates of interest are tumor-targeted antifolates, e.g. non-benzoyl 6-substituted straight chain pyrrolo[2,3- d ]pyrimidine antifolates, that are specific substrates for transporters other than RFC with limited expression and/or transport into normal tissues compared with tumors.
  • Examples of anthracyclines to be used in accordance with the present invention are daunorubicin, doxorubicin, epirubicin, idarubicin, and valrubicin.
  • Examples of platinum derivatives to be used in accordance with the invention are oxaliplatin, cisplatin, carboplatin, satraplanin, picoplatin, nedaplatin, and triplatin.
  • Examples of topoisomerase inhibitors to be used in accordance with the invention are irinotecan, topotecan, and camptothecin.
  • Examples of antimetabolites to be used in accordance with the invention are fluorouracil (5-FU), floxuridine, cytosine arabinoside, and 6-azauracil.
  • the present invention also relates to a kit for determining a folate administration regime as defined above.
  • a kit comprises some kind of means for quantifying, in a sample drawn from a patient, the expression level of at least one of the genes SLC46A1, SLC19A1, FPGS, ABCC3, MTHFD1L, GGH, MTHFD1, MTFMT, and ATIC.
  • the means may comprise an assay for analyzing the expression of one or more genes from one of the gene groups mentioned above (i.e. genes involved in folate transport (SLC46A1, SLC19A1, and ABCC3), folate polyglutamation (FPGS and GGH), and folate metabolism (MTHFD1L, MTHFD1, MTFMT, and ATIC), respectively).
  • the means comprises an assay for analyzing the expression of one or more genes from two of the groups.
  • the means comprises an assay for analyzing the expression of one or more genes from all of the three respective groups.
  • the means comprises an assay for analyzing the expression of each of the nine genes (SLC46A1, SLC19A1, ABCC3, FPGS, GGH, MTHFD1L, MTHFD1, MTFMT, and ATIC). In one embodiment, the means comprises an assay for analyzing the expression of SLC46A1 and/or SLC19A1.
  • the kit also comprises a leaflet indicating that a high expression level of at least one of the genes SLC46A1, SLC19A1, FPGS, ABCC3, MTHFD1L, GGH, MTHFD1, MTFMT, and ATIC, determines that the patient from which the sample is drawn is suited for a folate substance administration regime involving the administration of [6R]-MTHF and/or a folate substance upstreams of [6R]-MTHF in the metabolic pathway, and further that a low expression level of at least one of said genes SLC46A1, SLC19A1, FPGS, ABCC3, MTHFD1L, GGH, MTHFD1, MTFMT, and ATIC, determines that the patient from which the sample is drawn is suited for a folate substance administration regime involving the administration of [6R]-MTHF.
  • the invention also relates to a method for identifying a patient susceptible for a folate substance administration regime involving the administration of a folate substance upstreams of [6R]-MTHF in the metabolic pathway, as well as to a corresponding kit.
  • the invention also relates to a method for identifying a patient particularly suited for a folate substance administration regime involving the administration of [6R]-MTHF, as well as to a corresponding kit.
  • the underlying inventive concept also provides for a method for identifying a patient susceptible for a cancer treatment involving the administration of an anti-cancer agent (e.g. 5-FU) and a folate substance upstreams of [6R]-MTHF in the metabolic pathway (e.g. leucovorin), as well as a corresponding kit.
  • an anti-cancer agent e.g. 5-FU
  • a folate substance upstreams of [6R]-MTHF in the metabolic pathway e.g. leucovorin
  • the underlying inventive concept also provides for a method for identifying a patient who is not susceptible for a cancer treatment involving the administration of an anti-cancer agent (e.g. 5-FU) and a folate substance upstreams of [6R]-MTHF in the metabolic pathway (e.g. leucovorin), as well as a corresponding kit.
  • an anti-cancer agent e.g. 5-FU
  • a folate substance upstreams of [6R]-MTHF in the metabolic pathway e.g. leucovorin
  • the underlying inventive concept also provides for a method for identifying a patient particularly suited for a cancer treatment involving the administration of an anti-cancer agent (e.g. 5-FU) and [6R]-methylenetetrahydrofolate, as well as a corresponding kit.
  • an anti-cancer agent e.g. 5-FU
  • [6R]-methylenetetrahydrofolate e.g. 5-FU
  • the inventive concept of identifying specific patient groups being susceptible for specific folate substance treatments also provides for establishing new further medical uses of folate substances upstreams of [6R]-MTHF in the metabolic pathway, [6R]-MTHF, and anti-cancer agents.
  • the present invention provides for an anti-cancer agent (e.g. 5-FU) and a folate substance upstreams of [6R]-MTHF in the metabolic pathway (e.g. leucovorin) for use in the treatment of cancer in a patient showing a high expression level of at least one of the genes SLC46A1, SLC19A1, FPGS, ABCC3, MTHFD1L, GGH, MTHFD1, MTFMT, and ATIC.
  • an anti-cancer agent e.g. 5-FU
  • a folate substance upstreams of [6R]-MTHF in the metabolic pathway e.g. leucovorin
  • the present invention also provides for an anti-cancer agent (e.g.
  • Example 1 The aim of Example 1 was to identify genes in the folate pathway with possible impact on the metabolism of LV, given according to the Nordic bolus regime ( Carlsson , et al.; Sequential 5-fluorouracil and leucovorin in patients with advanced symptomatic gastrointestinal cancer, Eur J Cancer 1990;26:874-6 ). Relative expression of 22 genes putatively involved in transport, polyglutamation and metabolism of LV was determined and related to disease-free survival (DFS) of patients with stage III colorectal cancer, who were given adjuvant treatment with FLV or with 5-FU, LV and oxaliplatin (FLOX).
  • DFS disease-free survival
  • TMM Tumor-Node-Metastasis
  • FLV treatment comprised intravenous bolus injections of 5-FU (500 mg/m 2 ), followed by LV (60 mg/m 2 ) 30-40 minutes later, once weekly or on Days 1 and 2 every other week, according to the Nordic FLV regime ( Carlsson , et al.; Sequential 5-fluorouracil and leucovorin in patients with advanced symptomatic gastrointestinal cancer, Eur J Cancer 1990;26:874-6 ).
  • FLOX treatment comprised 5-FU (500 mg/m 2 ) and LV (60 mg/m 2 ) bolus on Days 1 and 2 every other week, plus an oxaliplatin infusion (85 mg/m 2 ) over 120 minutes on Day 1 every other week ( Sorbye H, Dahl O; Nordic 5-fluorouracil/leucovorin bolus schedule combined with oxaliplatin (Nordic FLOX) as first-line treatment of metastatic colorectal cancer, Acta Oncol 2003;42:827-31 ).
  • TLDA TaqMan ® Low-Density Array
  • Custom-designed TLDA cards containing 24 individual assays were ordered from Applied Biosystems at http://www.appliedbiosystems.com.
  • Three samples and one calibrator (SK-N-AS) were loaded to each card according to the manufacturer's instructions; each reservoir contained 83 ng of RNA converted to cDNA in a total volume of 100 ⁇ l. Two test runs were performed before the actual analysis.
  • Quantitative polymerase chain reactions were set up in duplicates in 384-well plates using the Biomek FX pipetting robot (Beckman Coulter) and were carried out in 10 ⁇ l reactions with 1 ⁇ TaqMan ® Gene Expression Mastermix (Applied Biosystems), 1 ⁇ gene-specific assay and 7.5 ng RNA converted into cDNA. Both TLDA cards and individual QPCR plates were run and analyzed by the ABI PRISM ® 7900HT Sequence Detection System (SDS 2.2, Applied Biosystems) according to the manufacturer's protocol. Calculations were performed using the ⁇ Ct relative quantification method. The thresholds and baselines were set manually in SDS and Ct values were extracted. All Ct values were normalized to the mean of the endogenous house-keeping genes ⁇ -actin and GAPDH for each sample.
  • Cox regression was performed individually for each gene, for each gene for expression values from mucosa and tumor separately, and for one censor variable at a time. Furthermore, the difference between the mucosa and tumor was investigated in a separate model for each gene. Each of these models was fitted both with and without the additional selected clinical covariates to examine their influence on the models. Additionally, each pair of genes (tumor and mucosa) was fitted together to a Cox model in the same fashion, to examine possible interactions.
  • the optimal cutoff values were derived for one gene at the time. For each gene all possible cutoff values where none of the two groups consisted of less than 25% of the total number of observations were tested. Each cutoff value was tested through a logrank test comparing survival distributions of the two groups, and the cutoff value resulting in the smallest p-value from the logrank test was selected.
  • the multivariate Cox regression analysis included the parameters gender, age, lymph node ratio, tumor differentiation grade and adjuvant therapy (FLV or FLOX). Due to very low expression values of the house-keeping genes, one patient was considered to be an outlier and was excluded from the Cox regression analysis.
  • FLV or FLOX tumor differentiation grade and adjuvant therapy
  • the two variables that emerged and which were included in the model were lymph node ratio and adjuvant therapy. Both varied to some extent in the different models, with lymph node ratio constantly having values of p ⁇ 0.01, while adjuvant therapy was significant (at the p ⁇ 0.05 level) in only 42% of the models, although it constantly had values of p ⁇ 0.1.
  • FIG. 1 shows the estimated survival functions by level of SLC46A1/PCFT gene expression in colorectal cancer tissue.
  • the two curves show predicted survival functions for the fitted Cox proportional hazards models.
  • the expression levels for the two curves have been set one standard deviation above, and one standard deviation below the mean, where one standard deviation corresponds to a fold change in log expression levels of 1.57.
  • Lymph node ratio has been set to its mean, and adjuvant therapy has been set to FLV since it was the treatment given to a majority of the patients. Standard deviations and mean for expression levels have been calculated from ⁇ Ct values.
  • Embodiment 1 A method for determining a folate substance administration regime, said method comprising:
  • Embodiment 2 A method according to embodiment 1, wherein the step of quantifying the expression level of at least one of said genes is performed by real-time quantitative PCR.
  • Embodiment 3 A method according to embodiment 1 or 2, wherein the quantified expression level for each of said genes is expressed as the Ct value normalized to the mean of the Ct values for the endogenous house-keeping genes ⁇ -actin and GAPDH.
  • Embodiment 4 A method according to any one of the preceding embodiments, wherein the step of establishing whether said expression level is high or low comprises comparing the expression level of at least one of said genes with a predetermined cutoff value.
  • Embodiment 5 A method according to embodiment 4, wherein:
  • Embodiment 6 A method according to any one of the preceding embodiments, wherein the folate substance upstreams of [6R]-methylenetetrahydrofolate in the metabolic pathway is selected from the group consisting of folic acid (pteroyl-L-glutamic acid), mefolinate ([6R,S]-5-CH 3 -tetrahydrofolate), Metafolin ® ([6S]-5-CH 3 -tetrahydrofolate), CoFactor ® ([6R,S]-5-CH 2 -tetrahydrofolate), levoleucovorin ([6S]-5-CHO-tetrahydrofolate) and/or leucovorin ([6R,S]-5-CHO-tetrahydrofolate), preferably levoleucovorin or leucovorin.
  • folic acid pteroyl-L-glutamic acid
  • mefolinate [6R,S]-5-CH 3 -te
  • Embodiment 7 A method according to any one of the preceding embodiments, wherein said folate substance administration regime is part of a cancer treatment.
  • Embodiment 8 A method according to any one of the preceding embodiments, said method comprising quantifying the expression level of at least one of the genes SLC46A1, SLC19A1, and ABCC3; at least one of the genes FPGS, and GGH; and at least one of the genes MTHFD1L, MTHFD1, MTFMT, and ATIC.
  • Embodiment 9 A method according to any one of the preceding embodiments, wherein said sample is drawn from a tumor of said patient, such as a solid tumor.
  • Embodiment 10 Kit for determining a folate substance administration regime, said kit comprising:
  • Embodiment 11 Method for identifying a patient susceptible for a folate substance administration regime involving the administration of a folate substance upstreams of [6R]-methylenetetrahydrofolate in the metabolic pathway, said method comprising:
  • Embodiment 12 Kit for identifying a patient susceptible for a folate substance administration regime involving the administration of a folate substance upstreams of [6R]-methylenetetrahydrofolate in the metabolic pathway, said method comprising:
  • Embodiment 13 Method for identifying a patient particularly suited for a folate substance administration regime involving the administration of [6R]-methylenetetrahydrofolate, said method comprising:
  • Embodiment 14 Kit for identifying a patient particularly suited for a folate substance administration regime involving the administration of [6R]-methylenetetrahydrofolate, said method comprising:
  • Embodiment 15 An anti-cancer agent and a folate substance upstreams of [6R]-methylenetetrahydrofolate in the metabolic pathway for use in the treatment of cancer in a patient showing a high expression level of at least one of the genes SLC46A1, SLC19A1, FPGS, ABCC3, MTHFD1L, GGH, MTHFD1, MTFMT, and ATIC.
  • Embodiment 16 An anti-cancer agent and [6R]-methylenetetrahydrofolate for use in the treatment of cancer in a patient showing a low expression level of at least one of the genes SLC46A1, SLC19A1, FPGS, ABCC3, MTHFD1L, GGH, MTHFD1, MTFMT, and ATIC.

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